<?php /* Smarty version 2.6.26, created on 2014-12-19 01:00:55
         compiled from page/sign_up.html */ ?>

<h2>Form Pendaftaran</h2>

<div class="wrapper">
	<div class="row">
		<div class="col-md-4 col-md-offset-4">
		<form role="form" onsubmit="return checkForm(this);">
		  <div class="form-group">
		  	<label for="">Nama Lengkap</label>
		  	<input type="text" class="form-control" id="nama" name="nama" placeholder="Full Name" required>
		  </div>
		  <div class="form-group">
		  	<label for="Username">Username</label>
		  	<input type="text" class="form-control" id="Username" name="username"placeholder="Username" required>
		  </div>
		  <div class="form-group">
		    <label for="Password">Password</label>
		    <input type="password" class="form-control" id="Password" name="password" placeholder="Password" required>
		  </div>
		  <div class="form-group">
		  	<label>Alamat</label>
		  	<textarea class="form-control" rows="5" maxlength="250" name="alamat" required></textarea>
		  </div>
		  <div class="form-group">
		  	<label>Kode Pos</label>
		  	<input type="text" class="form-control" name="kodepos" placeholder="5XXXX" required>
		  </div>
		  <div class="form-group">
		  	<label>Tanggal Lahir</label>
		  	<input type="datetime" class="form-control" name="tgllahir" placeholder="YYYY-MM-DD" required>
		  </div>
		  <div class="form-group">
		    <label for="Email1">Email</label>
		    <input type="email" class="form-control" id="Email1" name="email" placeholder="you@example.com" required>
		  </div>
		  <div class="form-group">
		  	<label>No HP</label>
		  	<input type="text" class="form-control" name="nohp" placeholder="08xxxxxxxxxx" required>
		  </div>
		  <div class="checkbox">
		    <label>
		      <input type="checkbox" required name="terms"> Agree <a href="">Privacy and Terms</a>
		    </label>
		  </div>
		  <button type="submit" class="btn btn-success form-control">Submit</button>
		</form>
		</div>
	</div>
</div>